A Learjet 31 took off before daybreak from Helena Regional
Airport in Montana, carrying six Veterans Affairs medical providers and 250
doses of historic cargo cradled in a plug-in cooler designed to minimize breakage.
Even in a state where 80-mph speed limits are normal, ground transportation
across long distances is risky for the Moderna mRNA-1273 vaccine, which must be
used within 12 hours of thawing.
The group’s destination was Havre, Montana, 30 miles from the Canadian border.
About 500 military veterans live in and around this small town of roughly
9,800, and millions more reside in similarly rural, hard-to-reach areas across
the United States.
About 2.7 million veterans who use the VA health system are classified as
“rural” or “highly rural” patients, residing in communities or on land with
fewer services and less access to health care than those in densely populated
towns and cities. An additional 2 million veterans live in remote areas who do
not receive their health care from VA, according to the department. To ensure
these rural vets have access to the COVID-19 vaccines, the VA is relying on a
mix of tools, like charter and commercial aircraft and partnerships with
civilian health organizations.
The challenges of vaccinating veterans in rural areas — which the VA considers
anything outside an urban population center — and “highly rural” areas —
defined as having fewer than 10% of the workforce commuting to an urban hub and
with a population no greater than 2,500 — extend beyond geography, as more than
55% of them are 65 or older and at risk for serious cases of covid and just 65%
are reachable via the internet.
For the Havre event, VA clinic workers called each patient served by the Merril
Lundman VA Outpatient Clinic in a vast region made up of small farming and
ranching communities and two Native American reservations. And for those
hesitant to get the vaccine, a nurse called them back to answer questions.
“At least 10 additional veterans elected to be vaccinated once we answered
their questions,” said Judy Hayman, executive director of the Montana VA Health
Care System, serving all 147,000 square miles of the state.
The Havre mission was a test flight for similar efforts in other rural
locations. Thirteen days later, another aircraft took off for Kalispell,
Montana, carrying vaccines for 400 veterans.
In Alaska, another rural state, Anchorage Veterans Affairs Medical Center
administrators finalized plans for providers to hop a commercial Alaska Airlines
flight on Thursday to Kodiak Island. There, VA workers expected to administer
100 to 150 doses at a vaccine clinic conducted in partnership with the Kodiak
Area Native Association.
“Our goal is to vaccinate all veterans who have not been vaccinated in and
around the Kodiak community,” said Tom Steinbrunner, acting director of the
Alaska VA Healthcare System.
VA began its outreach to rural veterans for the vaccine program late last year,
as the Food and Drug Administration approached the dates for issuing emergency
use authorizations for the Pfizer-BioNTech and Moderna vaccines, according to
Dr. Richard Stone, the Veterans Health Administration’s acting undersecretary.
It made sense to look to aircraft to deliver vaccines. “It just seemed logical
that we would reach into rural areas that, [like] up in Montana, we had a
contract with, a company that had small propeller-driven aircraft and short
runway capability,” said Stone, a retired Army Reserve major general.
Veterans have responded, Stone added, with more than 50% of veterans in rural
areas making appointments.
As of Wednesday, the VA had tallied 220,992 confirmed cases of COVID-19 among
veterans and VA employees and 10,065 known deaths, including 128 employees. VA
had administered 1,344,210 doses of either the Pfizer or Moderna vaccine,
including 329,685 second vaccines, to veterans as of Wednesday. According to
the VA, roughly 25% of those veterans live in rural areas, 2.81% live in highly
rural areas and 1.13% live on remote islands.
For rural areas, the VA has primarily relied on the Moderna vaccine, which
requires cold storage between minus 25 degrees Centigrade (minus 13 degrees
Fahrenheit) and minus 15 degrees C (5 degrees F) but not the deep freeze needed
to store the Pfizer vaccine (minus 70 degrees C, or minus 94 degrees F). That,
according to the VA, makes it more “transportable to rural locations.”
The VA anticipates that the one-dose Johnson & Johnson vaccine, if it
receives an emergency use authorization from the FDA, will make it even easier
to reach remote veterans. The vaccines from Moderna and Pfizer-BioNTech both
require two shots, spaced a few weeks apart. “One dose will make it easier for
veterans in rural locations, who often have to travel long distances, to get
their full vaccination coverage,” said VA spokesperson Gina Jackson. The FDA’s
vaccine advisory committee is set to meet on Feb. 26 to review J&J’s
application for authorization.
Meanwhile, in places like Alaska, where hundreds of veterans live off the grid,
VA officials have had to be creative. Flying out to serve individual veterans
would be too costly, so the Anchorage VA Medical Center has partnered with
tribal health care organizations to ensure veterans have access to a vaccine.
Under these agreements, all veterans, including non-Native veterans, can be
seen at tribal facilities.
“That is our primary outreach in much of Alaska because the tribal health
system is the only health system in these communities,” Steinbrunner said.
In some rural areas, however, the process has proved frustrating. Army veteran
John Hoefen, 73, served in Vietnam and has a 100% disability rating from the VA
for Parkinson’s disease related to Agent Orange exposure. He gets his medical
care from a VA location in Canandaigua, New York, 20 miles from his home, but
the facility hasn’t made clear what phase of the vaccine rollout it’s in,
Hoefen said.
The hospital’s website simply says a staff member will contact veterans when
they become eligible — a “don’t call us, we’ll call you,” situation, he said.
“I know a lot of veterans like me, 100% disabled and no word,” Hoefen said. “I
went there for audiology a few weeks ago and my tech hadn’t even gotten her
vaccine yet.”
VA Canandaigua referred questions about the facility’s current phase back to its
website: “If you’re eligible to get a vaccine, your VA health care team will
contact you by phone, text message or Secure Message (through MyHealtheVet) to
schedule an appointment,” it states. A call to the special COVID-19 phone
number established for the Canandaigua VA, which falls under the department’s
Finger Lakes Healthcare System, puts the caller into the main menu for hospital
services, with no information specifically on vaccine distribution.
For the most part, the VA is using Centers for Disease Control and Prevention
guidelines to determine priority groups for vaccines. Having vaccinated the
bulk of its health care workers and first responders, as well as residents of
VA nursing homes, it has been vaccinating those 75 and older, as well as those
with chronic conditions that place them at risk for severe cases of covid. In
some locations, like Anchorage and across Montana, clinics are vaccinating
those 65 and older and walk-ins when extra doses are available.
According to Lori FitzGerald, chief of pharmacy at the VA hospital in Fort
Harrison, Montana, providers have ended up with extra doses that went to
hospitalized patients or veterans being seen at the facility. Only one dose has
gone to waste in Montana, she said.
To determine eligibility for the vaccine, facilities are using the Veterans
Health Administration Support Service Center databases and algorithms to help
with the decision-making process. Facilities then notify veterans by mail,
email or phone or through VA portals of their eligibility and when they can
expect to get a shot, according to the department.
Air Force veteran Theresa Petersen, 83, was thrilled that she and her husband,
an 89-year-old U.S. Navy veteran, were able to get vaccinated at the Kalispell
event. She said they were notified by their primary care provider of the
opportunity and jumped at the chance.
“I would do anything to give as many kudos as I can to the Veterans Affairs
medical system,” Petersen said. “I’m so enamored with the concept that ‘Yes,
there are people who live in rural America and they have health issues too.’”
The VA is allowed to provide vaccines only to veterans currently enrolled in VA
health care. About 9 million U.S. veterans are not enrolled at the VA,
including 2 million rural veterans.
After veterans were turned away from a VA clinic in West Palm Beach, Florida,
in January, Rep. Debbie Wasserman Schultz (D-Fla.) wrote to Acting VA Secretary
Dat Tran, urging him to include these veterans in their covid vaccination
program.
Stone said the agency does not have the authorization to provide services to
these veterans. “We have been talking to Capitol Hill about how to reconcile
that,” he said. “Some of these are very elderly veterans and we don’t want to
turn anybody away.”